Whitney Child Centre Enrolment/Emergency FormStudent SurnameStudent NameDate of Admission DD MM YYYY Male Female (Please circle)Date of Birth DD MM YYYY Home AddressPostal CodeHome PhoneEmail AddressParent 1 InformationHome address as above or:Parent/Guardian NameHome Address, as above or:Postal CodeHome PhoneCell PhoneBusiness PhoneEmail AddressParent 2 InformationHome address as above or:Parent/Guardian NameHome AddressPostal CodeHome PhoneCell PhoneBusiness PhoneEmail AddressBusiness Address for one parentPostal CodeParent 3 InformationHome address as above or:Parent/Guardian NameHome Address, as above orHome PhoneCell PhoneBusiness PhoneEmail AddressParent 4 InformationHome address as above or:Home Address, as above orHome PhoneCell PhoneUntitledBusiness PhoneEmail AddressBusiness AddressPlease indicate which parent (1,2,3,4)Business AddressPostal CodePhoneChild's NameEmergency Contact 1Other than parent/guardianNameRelationshipAddress including Postal CodeHome PhoneBus/Cell PhoneEmergency Contact 2Other than parent/guardianNameRelationshipAddress including Postal CodeHome PhoneBus/Cell PhoneDoctor InformationName of DoctorDoctor's AddressPostal CodePhoneDate of last tetanus shot (DPTP) DD MM YYYY Drug AllergiesFood/Other AllergiesDoes your child have anaphylactic symptoms? What symptoms do you see if your child is exposed to allergen?Dietary RestrictionsAny medical conditionsOther than parents, people authorized to pick up your childNameRelationshipPhoneNameRelationshipPhoneNameRelationshipPhoneNameRelationshipPhoneParent SignatureNameDate DD MM YYYY